Retired Osprey resident Jim Koeniger, 67, says he knew it was time for hip replacement surgery when progressive bone degeneration in his right hip made it unbearable to walk.
“I couldn’t take five steps without excruciating pain,” says the bonsai tree hobbyist and landscape gardener.
After a hip replacement, Jim Koeniger has no problem doing yardwork at his home in Osprey. (July 21, 2014) (Herald-Tribune staff photo by Dan Wagner)
Before choosing a surgeon to do the operation, Koeniger says he did “fastidious research” on total hip replacement surgery and discovered there was more than one way for orthopedic surgeons to access the hip joint during surgery — through the back or front — and that it could make a real difference.
Traditional hip replacement surgery requires creating an incision on the patient’s side or toward the back, and cutting through muscles and tendons to reach the joint. Surgeons who prefer the anterior approach avoid cutting through muscles by making a smaller incision at the front of the hip.
Proponents of the newer technique say recovery is faster and less painful, mobility is achieved more easily and this method reduces risk of postoperative dislocation
“I went with the anterior approach. All of the technical stuff made so much logical sense,” says Koeniger, who compared medical studies about the procedures. One video he watched showed his Sarasota orthopedic surgeon, Edward Stolarski, teaching the anterior technique to a group of surgeons visiting from Japan.
Dr. Michael Parks — spokesperson and board member at the American Academy of Orthopaedic Surgeons and attending surgeon at the Hospital for Special Surgery in New York City — says both approaches work, and both have complications.
“In essence, anterior is a muscle-sparing approach,” he says. “Two muscles are split, and you are able to go between those two groups but you still have to cut the tissue. In the posterior approach, the buttock muscle is split, which exposes the tendons and those are cut.
Parks says that if the anterior method has benefits, they are subtle.
“If there are improvements, it’s very early on,” he says. “Anterior patients have a slightly higher edge in immediate mobility and shorter hospital stays. There may be an advantage for pain relief, but at six weeks and three months they are comparable.”
A third option, most commonly known as the SuperPath technique, involves accessing the joint from the top through a small incision and assembling the hip replacement inside the body. Developed by an Arizona orthopedic surgeon, this alternative method has not yet been independently evaluated, but is said to speed recovery because it involves no dislocation of the hip joint. About two dozen U.S. surgeons now perform the procedure, including John T. Moor, of the Advanced Sports Medicine Center in Sarasota.
Parks says he and the majority of surgeons use the posterior method. For him, it provides more flexibility when larger incisions and better visibility are necessary.
Not all patients are candidates for a nontraditional hip replacement. Stolarski says he still uses the posterior approach when necessary — typically when doing complicated revision work — because it affords wider access to the femur and socket.
Koeniger reports that recovering from anterior surgery this past March was actually somewhat slower and more painful than he expected. But he still felt satisfied because it provided certain freedoms he couldn’t get with a conventional procedure.
“Traditional surgery requires being very careful of how you bend over and position your body. I didn’t have to be careful; I didn’t even think about it,” says Koeniger. “I’m now lifting stuff that’s 200 to 250 pounds and jumping in and out of my truck. It’s amazing.”
A MATTER OF SKILL?
When it comes to complications with the anterior method — as compared to standard hip replacement surgery — maybe the burden of proof is on the surgeon, and not the technique itself.
A study published in the March 2013 Orthopedics Today observed a 16 percent overall complication rate among 61 anterior hip replacement surgery patients in an academic setting.
“A high complication rate, particularly during a surgeon’s learning curve, has been reported,” the researchers wrote.
“I agree that the learning curve can be challenging,” says Stolarski. “Experience is key.”
In the right hands, he maintains, patients benefit from the anterier method: “It’s more accurate, and no hip precautions, no special toilet; they can sleep the way they want, bend over past 90 degrees, can go back to high-risk activity like kayaking, police work and skiing with a significantly reduced risk of dislocation.”
The American Academy of Orthopaedic Surgeons says state and federal health agencies do not collect information to show how many surgeons use the anterior approach, but says that is likely to change.
In 2011, the Association of Bone and Joint Surgeons published a study of 800 patients who had anterior-approach hip replacement surgery. They uncovered a variety of complications, with fractures being the most common intraoperative problem and wound-healing issues encountered most frequently postoperatively.
“The downside of the anterior approach is a higher rates of complications — wound problems, hematomas,” Parks says. “But it may be skill-related too. There is increased blood loss, longer surgery, a different visualization. Sciatic nerve injury can occur with the posterior approach, but there’s less incidence of heterotopic ossification.”
Heterotopic ossification means abnormal bone has developed in soft-tissue areas where bone does not naturally exist. Some research suggests that patients who choose the anterior technique may be at higher risk, but evidence is inconclusive.
“Experienced anterior surgeons are not seeing the above problems,” says Stolarski, who says he has done over 3,000 anterior operations himself.
APPLES TO ORANGES
Two-time hip replacement patient Jocelyn Bieluch, 62, is an Englewood snowbird from Connecticut who had her first, posterior-style hip surgery last October.
Her recovery was tough, she says. When it came time to repair the other side in March this year, she chose anterior surgery with Stolarski after hearing about it from a relative.
She says the two surgeries were as different as apples and oranges, with the first requiring a four-day hospital stay and second only two days.
“Before, when I came to, I was in excruciating pain. Every step was excruciating,” says Bieluch.
She also faced a height discrepancy and associated back pain, which isn’t uncommon after traditional hip replacement surgery. Her surgeon said she should address the disparity by wearing a lift in her shoe.
“The second one was so different, amazingly different,” Bieluch recalls. “I was moving right from the first day. I was happy, relieved.”
Parks says he does a couple hundred traditional hip joint replacements annually and most of these patients are also spending less time in the hospital — due in part to more attention paid to pain management and physical therapy.
“We used to keep patients in the hospital four or five days,” Parks says. “Now we send patients home an average of two days earlier, and most of us use the posterior approach.”
As for Bieluch’s height irregularity, which was corrected during the second surgery, Parks says, “height discrepancy is independent of approach.”
Stolarski counters with the argument that having anterior patients lie on their backs during surgery “provides for the most accurate leg lengths possible” — which is measured with a live X-ray in the operating room.
“Also, the surgeon can go to the foot of the bed and feel the length of the leg. Neither of these things can be done from a posterior approach,” he adds. “The posterior approach is mostly indirect measuring, and guessing for leg length.”
Parks says it’s essential to keep in mind that both methods provide successful long-term results, every surgery comes with risk, and finding a busy surgeon with a good track record is what matters most.
“Hip replacement works. They all work very well in terms of mobility,” Parks says. “What’s most important for patients is finding a doctor you are comfortable with, and doctors who do a lot of them.”
For Bieluch, her second choice was her best.
“I can’t take the smile off my face. I have no pain, my legs are even and my back doesn’t hurt anymore,” says Bieluch. “I feel like I have a second chance at life now.”
